Management of Acute Allergic Reactions (Paediatrics)
Management of Acute Allergic Reactions and Anaphylaxis in Children and Young PeopleThe purpose of this guideline is to assist those working in the Emergency Department and on the children’s wards and outpatients to promptly recognise and manage moderate to severe allergic reactions in children and young people.Making the diagnosis:Allergic reactions in children are common and usually secondary to having come into contact with a food substance (commonly milk or eggs, peanuts, tree nuts or seafood). Anaphylactic reactions to bee stings, drugs and latex are less common. Children with mild urticarial reactions commonly present to hospital. These are often secondary to a viral illness but a full history should be taken and assessment made to rule out potential anaphylaxis. Anaphylaxis is likely when the following 2 criteria are met:Sudden onset and rapid progression of symptomsLife threatening Airway and / or Breathing and / or Circulation problemsSkin and / or mucosal changes (flushing, urticaria, angioedema) may also be present or absentRecent exposure to a known or common allergen supports the diagnosis of an allergic reaction but does not exclude itRemember:Skin or mucosal changes alone are not a sign of an anaphylactic reactionSkin and mucosal changes can be subtle or absent in up to 20% of reactions (some patients can have only a decrease in blood pressure i.e. a circulation problem)There can also be gastrointestinal symptoms (e.g. vomiting, abdominal pain, incontinence)Early administration of IM Adrenaline is life-saving in AnaphylaxisBEWARE – A LATE PHASE REACTION MAY OCCUR UP TO 72 HOURS POST EXPOSUREUse the ABCDE approach to recognise an anaphylactic reaction (any of the highlighted signs represent anaphylaxis)-76200125095Airway Pharyngeal/ laryngeal oedemaSwelling of tongueHoarse voice StridorBreathing:Increase respiratory rateWheezeConfused by hypoxiaHypoxiaRespiratory arrest00Airway Pharyngeal/ laryngeal oedemaSwelling of tongueHoarse voice StridorBreathing:Increase respiratory rateWheezeConfused by hypoxiaHypoxiaRespiratory arrest3248025125095CirculationSigns of shock – pale, clammyTachycardiaHypotensionCollapseDisabilityDowsinessConfusion or agitationExposureExposureFlushingErythematous / urticarial rashAngioedema00CirculationSigns of shock – pale, clammyTachycardiaHypotensionCollapseDisabilityDowsinessConfusion or agitationExposureExposureFlushingErythematous / urticarial rashAngioedemaManagement of acute allergic reactions in childrenAssess ABCDE and remove the allergen if appropriate. Treat the conditions below accordingly (Drug doses on the next page)-257175132080Angioedema / UrticariaOral Cetirizine/Chorphenamine and consider alsoOral Prednisolone particularly if the child has already received an antihistamine but continued to have symptoms such as urticaria.00Angioedema / UrticariaOral Cetirizine/Chorphenamine and consider alsoOral Prednisolone particularly if the child has already received an antihistamine but continued to have symptoms such as urticaria.2179320132080WheezeHigh flow oxygenIntramuscular Adrenalinealbutamol via nebuliser or via spacerIf no response in 5 mins:Repeat intramuscular Adrenaline Repeat nebulised SalbutamolCall the on call anaesthetist +/- resus team Give intravenous Hydrocortisone AND oral Cetrizine/Chlorphenamine to prevent a late phase reaction. For all severe or recurrent reactions, and for all children with known asthma, give IV Hydrocortisone and consider IM or IV Chlorphenamine00WheezeHigh flow oxygenIntramuscular Adrenalinealbutamol via nebuliser or via spacerIf no response in 5 mins:Repeat intramuscular Adrenaline Repeat nebulised SalbutamolCall the on call anaesthetist +/- resus team Give intravenous Hydrocortisone AND oral Cetrizine/Chlorphenamine to prevent a late phase reaction. For all severe or recurrent reactions, and for all children with known asthma, give IV Hydrocortisone and consider IM or IV Chlorphenamine7267575118745Hypotension / collapseHigh flow oxygenIntramuscular Adrenalineaediatric resus team (2222)Intravenous / Intraosseous access Give 20ml/kg 0.9% SalineIf no response in 5 minutes:2nd dose of Intramuscular AdrenalineGive IV Hydrocortisone AND oral Cetirizine/Chlorphenamine to prevent a late phase reactionFor all severe or recurrent reactions, and for all children with known asthma, give IV Hydrocortisone and consider IM or IV Chlorphenamine00Hypotension / collapseHigh flow oxygenIntramuscular Adrenalineaediatric resus team (2222)Intravenous / Intraosseous access Give 20ml/kg 0.9% SalineIf no response in 5 minutes:2nd dose of Intramuscular AdrenalineGive IV Hydrocortisone AND oral Cetirizine/Chlorphenamine to prevent a late phase reactionFor all severe or recurrent reactions, and for all children with known asthma, give IV Hydrocortisone and consider IM or IV Chlorphenamine4676775118745StridorHigh flow oxygenIntramuscular Adrenalinen if severe upper airway obstruction is present, call the on call anaesthetist +/- resus team (2222) and give nebulised Adrenaline If no response in 5 minutes:2nd dose of Intramuscular AdrenalineRepeat nebulised Adrenaline Call the on call anaesthetistGive IV Hydrocortisone AND oral Cetirizine/Chlorphenamine to prevent a late phase reactionFor all severe or recurrent reactions, and for all children with known asthma, give IV Hydrocortisone and consider IM or IV Chlorphenamine00StridorHigh flow oxygenIntramuscular Adrenalinen if severe upper airway obstruction is present, call the on call anaesthetist +/- resus team (2222) and give nebulised Adrenaline If no response in 5 minutes:2nd dose of Intramuscular AdrenalineRepeat nebulised Adrenaline Call the on call anaesthetistGive IV Hydrocortisone AND oral Cetirizine/Chlorphenamine to prevent a late phase reactionFor all severe or recurrent reactions, and for all children with known asthma, give IV Hydrocortisone and consider IM or IV Chlorphenamine -257175107315Further management of severe anaphylaxis is available via the APLS folder in ED or the wardsor via Children’s Acute Transport Service (CATS) 0800 085 0003 cats.nhs.uk. Points to consider in the history:Was this a known allergen? Opportunity for educationIs the child asthmatic? This is an opportunity to optimise asthma control (this is the high risk group for fatal reactions)Do they have an Adrenaline auto-injector (Emerade? or Epipen?) and was management optimal? Opportunity for educationAre there other allergic symptoms or signs that need addressing? Opportunity to improve symptom controlDo they already have an emergency plan that needs to be modified? Opportunity to improve emergency plan00Further management of severe anaphylaxis is available via the APLS folder in ED or the wardsor via Children’s Acute Transport Service (CATS) 0800 085 0003 cats.nhs.uk. Points to consider in the history:Was this a known allergen? Opportunity for educationIs the child asthmatic? This is an opportunity to optimise asthma control (this is the high risk group for fatal reactions)Do they have an Adrenaline auto-injector (Emerade? or Epipen?) and was management optimal? Opportunity for educationAre there other allergic symptoms or signs that need addressing? Opportunity to improve symptom controlDo they already have an emergency plan that needs to be modified? Opportunity to improve emergency plan-8572588265DRUG DOSESAdrenalineAdrenaline 1:1000Adrenaline AutoinjectorAdrenaline (Nebulised)(Intramuscular IM) (Intramuscular IM)6mnths – 6yrs 0.15mls(150mcg)>6yrs150mcg5 mls (5mg) of the 1:1,000 solution6-12yrs0.3mls(300mcg)6-12yrs300mcg> 12yrs0.5mls(500mcg)>12yrs500mcg (Emerade? only)AntihistamineChlorphenamine (IV/IM)Chlorphenamine (oral)Cetirizine (oral)< 6mnths 250mcg/kg1mth-6yrs1mg<1yr250mcg/kg6mths-6yrs 2.5mg6-12yrs2mg1-2yrs2.5mg6-12yrs5mg>12yrs4mg2-6yrs5mg (double dose)>12yrs10mg6-12yrs10mg (double dose)>12yrs20mg (double dose)SteroidsHydrocortisone (IV)Prednisolone (oral)<6mths25mg2mg/kg max 40mg6mths –6yrs 50mg6-12rs100mg> 12yrs200mgBronchodilatorSalbutamol (Nebulised)Salbutamol (inhaled via spacer)<2yrs1.25mg 10 puffs of 100mcg2-5yrs2.5 mg>5yrs5mg00DRUG DOSESAdrenalineAdrenaline 1:1000Adrenaline AutoinjectorAdrenaline (Nebulised)(Intramuscular IM) (Intramuscular IM)6mnths – 6yrs 0.15mls(150mcg)>6yrs150mcg5 mls (5mg) of the 1:1,000 solution6-12yrs0.3mls(300mcg)6-12yrs300mcg> 12yrs0.5mls(500mcg)>12yrs500mcg (Emerade? only)AntihistamineChlorphenamine (IV/IM)Chlorphenamine (oral)Cetirizine (oral)< 6mnths 250mcg/kg1mth-6yrs1mg<1yr250mcg/kg6mths-6yrs 2.5mg6-12yrs2mg1-2yrs2.5mg6-12yrs5mg>12yrs4mg2-6yrs5mg (double dose)>12yrs10mg6-12yrs10mg (double dose)>12yrs20mg (double dose)SteroidsHydrocortisone (IV)Prednisolone (oral)<6mths25mg2mg/kg max 40mg6mths –6yrs 50mg6-12rs100mg> 12yrs200mgBronchodilatorSalbutamol (Nebulised)Salbutamol (inhaled via spacer)<2yrs1.25mg 10 puffs of 100mcg2-5yrs2.5 mg>5yrs5mgFurther management:In young people aged 16 years or older*, take timed blood samples for mast cell tryptase testing as follows:a sample as soon as possible after emergency treatment has starteda second sample ideally within 1–2 hours (but no later than 4 hours) from the onset of symptoms.*Consider in children under 16 years Admission criteria:Children < 16 yearsChildren younger than 16 with anaphylaxis should be observed for a minimum of 6 hours and admitted to hospital under the care of the paediatric medical team. Young People > 16 yearsYoung people aged 16 years or older with anaphylaxis should be observed for 6–12 hours from the onset of symptoms, depending on their response to emergency treatment. In those with reactions that are controlled promptly and easily, a shorter observation period may be considered provided that they receive appropriate post-reaction care prior to discharge.Important features to document:Time of onset of the reactionThe circumstances immediately before the onset of symptomsThe allergen if knownThe speed of onset of symptoms in relation to exposure to the allergenAll life-threatening problems involving:airway: pharyngeal or laryngeal oedemabreathing: bronchospasm with tachypnoeacirculation: hypotension and/or tachycardiaAny associated skin and mucosal changes.Discharge Checklist Identify trigger: Attempt to identify the allergen(s) and help the child / family make a plan how to avoid these. If an in-patient, ask the paediatric dietician to advise.Prescribe adrenalin injector and other medication: NICE and European guidance recommends for all patients following an anaphylactic reaction or patients who have had an allergic reaction and are asthmatic on inhaled steroids. Consider, (following discussion with the attending consultant), whether an injectable Adrenalin autoinjector for home use should be prescribed. If in doubt, ask one of the paediatric consultants responsible for the allergy clinic (Dr Goh, Salt, Cohen or Eisen). One dose should be prescribed for the patient/carer to carry at all times and ask the GP to prescribe another one for school /nursery.Epipens? are the most widely used adrenalin injectors however, Emerade? pens are becoming more common and are the brand stocked by our hospital pharmacy. They to use and are the only pens with a 500mcg doseEmerade? 150mcg - <25kgEmerade? 300mcg 25 to 45kgEmerade? 500mcg >45kgPrescribe antihistamine (Cetirizine preferred as longer acting and less sedating)Prescribe Salbutamol inhaler with age appropriate spacer if reaction involved respiratory symptomsAuto-injector training: If an Emerade?auto-injector is prescribed, the child / young person / family must be educated in its use. Use Emerade? training video: (show the carer/patient on their smart phone as you can’t watch YouTube on Trust computers). Face to face training can be organised via the allergy clinical nurse specialist, Tracey Bridges 07984464469 or tracey.bridges@uclh,nhs.uk and the relevant children’s community nursing team may be able to support education at home or in school. Written allergy management plan and PILS on allergic reactions: Provide a written BSACI written emergency allergy treatment plan with the Emerade? Patient information leaflet on Allergic Reactions and Anaphylaxis (provided in paeds ED) and refer to allergy clinic: NICE recommends all patients with anaphylaxis must be seen by a paediatric allergy specialist. For new patient who are local to UCLH refer urgently by email if local to UCLH Paedsallergygrading@ulch.nhs.uk and provide contact details for the family: Jackie Touray 02034477876. If out of area ask GP to refer to local allergy rmation of the GP: In the discharge summary explain the diagnosis, management plan and follow up for the GP. If out of area ask GP to refer to local paediatric allergy clinic unless already under UCLH or parents choose to be followed up at UCLH.Further information for families: Consider printing out parent information via especially if no internet access at home. Other useful websites: itchysneezywheezy.co.uk, .uk Identify trigger: Attempt to identify the allergen(s) and help the child / family make a plan how to avoid these. If an in-patient, ask the paediatric dietician to advise.Prescribe adrenalin injector and other medication: NICE and European guidance recommends for all patients following an anaphylactic reaction or patients who have had an allergic reaction and are asthmatic on inhaled steroids. Consider, (following discussion with the attending consultant), whether an injectable Adrenalin autoinjector for home use should be prescribed. If in doubt, ask one of the paediatric consultants responsible for the allergy clinic (Dr Goh, Salt, Cohen or Eisen). One dose should be prescribed for the patient/carer to carry at all times and ask the GP to prescribe another one for school /nursery.Epipens? are the most widely used adrenalin injectors however, Emerade? pens are becoming more common and are the brand stocked by our hospital pharmacy. They to use and are the only pens with a 500mcg doseEmerade? 150mcg - <25kgEmerade? 300mcg 25 to 45kgEmerade? 500mcg >45kgPrescribe antihistamine (Cetirizine preferred as longer acting and less sedating)Prescribe Salbutamol inhaler with age appropriate spacer if reaction involved respiratory symptomsAuto-injector training: If an Emerade?auto-injector is prescribed, the child / young person / family must be educated in its use. Use Emerade? training video: (show the carer/patient on their smart phone as you can’t watch YouTube on Trust computers). Face to face training can be organised via the allergy clinical nurse specialist, Tracey Bridges 07984464469 or tracey.bridges@uclh,nhs.uk and the relevant children’s community nursing team may be able to support education at home or in school. Written allergy management plan and PILS on allergic reactions: Provide a written BSACI written emergency allergy treatment plan with the Emerade? Patient information leaflet on Allergic Reactions and Anaphylaxis (provided in paeds ED) and refer to allergy clinic: NICE recommends all patients with anaphylaxis must be seen by a paediatric allergy specialist. For new patient who are local to UCLH refer urgently by email if local to UCLH Paedsallergygrading@ulch.nhs.uk and provide contact details for the family: Jackie Touray 02034477876. If out of area ask GP to refer to local allergy rmation of the GP: In the discharge summary explain the diagnosis, management plan and follow up for the GP. If out of area ask GP to refer to local paediatric allergy clinic unless already under UCLH or parents choose to be followed up at UCLH.Further information for families: Consider printing out parent information via especially if no internet access at home. Other useful websites: itchysneezywheezy.co.uk, .uk Discharge Checklist (see discharge checklist for guidance)371475071755Date: ____________________Consultant:________________00Date: ____________________Consultant:________________-3809944450Patient name:_________________Date of birth: _________________Hospital number: ______________00Patient name:_________________Date of birth: _________________Hospital number: ______________Suspected allergen:___________________________________________________________Co-factors: □ Unwell□ Asthma□ Medication□ Exercise□ Alcohol□ Other_______________________________________Reaction (please tick all symptoms):Localised symptoms onlySystemic reactionGrade 1Grade 2Grade 3Grade 4At least one of:□ Localised urticaria□ Localised angioedema□ Itchy mouth□ Mild nauseaAt least one of:□ Generalised urticarial or skin flushing□ Widespread angioedema□ Rhinitis□ Itchy eyes□ Gut: nausea and up to 1 vomitAt least one of:□ Respiratory: mild wheeze, SOB, responsive to Ventolin□ Gut: persistent vomiting or persistent abdominal painAt least one of:□ Stridor; swollen throat with respiratory symptoms□ Respiratory: wheeze/SOB not responsive to VentolinAt least one of:□ Respiratory: failure with or without loss of consciousness□ Cardiovascular: low BP/shock or collapseDischarge Medication (please tick the relevant medications):□ Antihistamine: Name and dose: _________________________________□ Adrenaline auto-injector: Name and dose:_________________________□ Bronchodilator: Name and dose:_________________________________□ Prednisolone: Dose:_________________________________□ Inhaled corticosteroid (step-up of asthma management): Name and dose:___________________ Before discharge the following was explained and written information provided (please tick the relevant ones):Recognising and managing an allergic reaction:□ BSACI allergy action plan□ Patient information leaflet on Allergic Reactions and Anaphylaxis□ Late phase reactions explainedUsing the adrenaline auto-injector:□ Demonstration on correct use of AAI □ Trainer auto-injector pen prescribed □ Show how to check expiry dateAvoidance of triggers:□ Advice about avoiding suspected triggers□ Free-from information provided Follow up and advice:□ Inform family that they will be referred to paediatric allergy service: □ If referring to UCLH provide family with UCLH allergy service contact: jackie.touray@uclh.nhs.uk □ Advised to see GP for 2nd AAI, antihistamines and salbutamol as required □ Documented in the ED discharge letterReferences:Resus Council (UK) Emergency treatment of anaphylactic reactions. Guidelines for healthcare providers. January 2008 .uk/pages/reaction.pdf NICE CG134 Anaphylaxis: assessment and referral after emergency treatment November 2011BNF for Children, BNFC February 2016. ADRENALINE/EPINEPHRINE. Available at: Product Characteristics. Emerade?, 150 micrograms, solution for injection in pre-filled pen. Last Updated on eMC 29-Jan-2016. Available at Product Characteristics. Emerade, 300 micrograms, solution for injection in pre-filled pen Last Updated on eMC 29-Jan-2016. Available at : Product Characteristics Emerade, 500 micrograms, solution for injection in pre-filled pen. Last Updated on eMC 01-Feb-2016. Available at: ................
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